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Bernat M, Boyer A, Roche M, Richard C, Bouvet L, Remacle A, Antonini F, Poirier M, Pastene B, Hammad E, Fond G, Bruder N, Leone M, Zieleskiewicz L. Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients. Anaesthesia 2024; 79:309-317. [PMID: 38205529 DOI: 10.1111/anae.16221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Global warming is a major public health concern. Volatile anaesthetics are greenhouse gases that increase the carbon footprint of healthcare. Modelling studies indicate that total intravenous anaesthesia is less carbon intensive than volatile anaesthesia, with equivalent quality of care. In this observational study, we aimed to apply the findings of previous modelling studies to compare the carbon footprint per general anaesthetic of an exclusive TIVA strategy vs. a mixed TIVA-volatile strategy. This comparative retrospective study was conducted over 2 years in two French hospitals, one using total intravenous anaesthesia only and one using a mixed strategy including both intravenous and inhalation anaesthetic techniques. Based on pharmacy procurement records, the quantity of anaesthetic sedative drugs was converted to carbon dioxide equivalents. The primary outcome was the difference in carbon footprint of hypnotic drugs per intervention between the two strategies. From 1 January 2021 to 31 December 2022, 25,137 patients received general anaesthesia in the hospital using the total intravenous anaesthesia strategy and 22,020 in the hospital using the mixed strategy. The carbon dioxide equivalent footprint of hypnotic drugs per intervention in the hospital using the total intravenous anaesthesia strategy was 20 times lower than in the hospital using the mixed strategy (emissions of 2.42 kg vs. 48.85 kg carbon dioxide equivalent per intervention, respectively). The total intravenous anaesthesia strategy significantly reduces the carbon footprint of hypnotic drugs in general anaesthesia in adult patients compared with a mixed strategy. Further research is warranted to assess the risk-benefit ratio of the widespread adoption of total intravenous anaesthesia.
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Affiliation(s)
- M Bernat
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - A Boyer
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Roche
- Pharmacy Department, Service Central des Opérations Pharmaceutiques, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - C Richard
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - L Bouvet
- Department of Anesthesia and Critical Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - A Remacle
- Departement of Medical Information, Hôpital Nord, Marseille, France
| | - F Antonini
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Poirier
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - B Pastene
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - E Hammad
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - G Fond
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France
| | - N Bruder
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - M Leone
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - L Zieleskiewicz
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France
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Dexter F, Hindman BJ. Systematic review with meta-analysis of relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. J Clin Anesth 2023; 90:111210. [PMID: 37481911 DOI: 10.1016/j.jclinane.2023.111210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023]
Abstract
The objective of this systematic review was to estimate the relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. Prolonged times are defined as ≥15 min from end of surgery (or anesthetic discontinuation) to extubation in the operating room. They are associated with reintubations, naloxone and flumazenil administration, longer times from procedure end to operating room exit, greater differences between actual and scheduled operating room times, longer times from operating room exit to next case start, longer durations of the workday, and more operating room personnel idle while waiting for extubation. Published randomized clinical trials of humans were included. Generalized pivotal methods were used to estimate the relative risk of prolonged extubation for each study from reported means and standard deviations of extubation times. The relative risks were combined using DerSimonian-Laird random effects meta-analysis with Knapp-Hartung adjustment. From 67 papers, there were 78 two-drug comparisons, including 5167 patients. Studies were of high quality (23/78) or moderate quality (55/78), the latter due to lack of blinding of observers to group assignment and/or patient attrition because patients were extubated after operating room exit. Desflurane resulted in a 65% relative reduction in the incidence of prolonged extubation compared with sevoflurane (95% confidence interval 49% to 76%, P < .0001) and in a 78% relative reduction compared with isoflurane (58% to 89%, P = .0001). There were no significant associations between studies' relative risks and quality, industry funding, or year of publication (all six meta-regressions P ≥ .35). In conclusion, when emergence from general anesthesia with different drugs are compared with sevoflurane or isoflurane, suitable benchmarks quantifying rapidity of emergence are reductions in the incidence of prolonged extubation achieved by desflurane, approximately 65% and 78%, respectively. These estimates give realistic context for interpretation of results of future studies that compare new anesthetic agents to current anesthetics.
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Hendrickx JFA, Nielsen OJ, De Hert S, De Wolf AM. The science behind banning desflurane: A narrative review. Eur J Anaesthesiol 2022; 39:818-824. [PMID: 36036420 DOI: 10.1097/eja.0000000000001739] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Potent inhaled anaesthetics are halogenated hydrocarbons with a large global warming effect. The use of fluorinated hydrocarbons (most are not anaesthetics) are being restricted but volatile anaesthetics have been exempted from legislation, until now: the EU has formulated a proposal to ban or at least severely restrict the use of desflurane starting January 2026. This narrative review addresses the implications of a politics-driven decision - without prior consultation with major stakeholders, such as the European Society of Anaesthesiology and Intensive Care (ESAIC) - on daily anaesthesia practice and reviews the potential scientific arguments that would support stopping the routine use of desflurane in anaesthetic practice. Of note, banning or severely restricting the use of one anaesthetic agent should not distract the user from sensible interventions like reducing fresh gas flows and developing technology to capture and recycle or destroy the wasted potent inhaled anaesthetics that we will continue to use. We call to join efforts to minimise our professional environmental footprint.
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Affiliation(s)
- Jan F A Hendrickx
- From the Department of Anesthesiology, Onze-Lieve-Vrouw Hospital, Aalst (JFAH), Department of Basic and Applied Medical Sciences, Ghent University, Ghent (JFAH, SDH), Department of Anesthesiology, University Hospital and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium (JFAH), Department of Chemistry, University of Copenhagen, Copenhagen, Denmark (OJN), Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium (SDH) and Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA (AMDW)
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Hu ZH, Liu Z, Zheng GF, Li ZW, Liu SQ. Postoperative Recovery Outcomes for Obese Patients Undergoing General Anesthesia: A Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 9:862632. [PMID: 35965859 PMCID: PMC9366090 DOI: 10.3389/fsurg.2022.862632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study was performed to assess the postoperative recovery outcomes in obese patients undergoing general anesthesia. Methods The eligible studies were identified from PubMed, EmBase, and the Cochrane library until December 2020. The standard mean differences (SMDs) with 95% confidence intervals (CIs) were used to calculate the role of desflurane, sevoflurane, and propofol on recovery outcomes, and the analyses using the random-effects model. Results Eleven randomized controlled trials involving 713 obese patients undergoing general anesthesia were selected for final meta-analysis. We noted desflurane was associated with a shorter time to eye-opening than sevoflurane (SMD: −0.86; 95% CI, −1.43 to −0.28; P = 0.003). The use of desflurane with shorter time to extubation as compared with propofol (SMD: −1.13; 95% CI, −1.52 to −0.73; P < 0.001) or sevoflurane (SMD: −1.19; 95% CI, −2.15 to −0.22; P = 0.016), while sevoflurane was associated with longer time to extubation as compared with propofol (SMD: 1.47; 95% CI, 1.03 to 1.91; P < 0.001). Desflurane were associated with shorter time to stating name as compared with propofol (SMD: −1.40; 95% CI, −2.32 to −0.48; P = 0.003) or sevoflurane (SMD: −2.09; 95% CI, −3.33 to −0.85; P = 0.001). In addition, desflurane was associated with a longer time for orientation to place as compared with propofol (SMD: 0.65; 95% CI, 0.22 to 1.07; P = 0.003), while desflurane with shorter time for orientation to place as compared with sevoflurane (SMD: −0.88; 95% CI, −1.46 to −0.30; P = 0.003). Conclusions The use of desflurane could provide better recovery outcomes in obese patients undergoing general anesthesia. Further large-scale trials should be comparison the long-term effectiveness of various anesthetics.
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Seyni-Boureima R, Zhang Z, Antoine MMLK, Antoine-Frank CD. A review on the anesthetic management of obese patients undergoing surgery. BMC Anesthesiol 2022; 22:98. [PMID: 35382771 PMCID: PMC8985303 DOI: 10.1186/s12871-022-01579-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/27/2022] [Indexed: 12/01/2022] Open
Abstract
There has been an observed increase in theprevalence of obesity over the past few decades. The prevalence of anesthesiology related complications is also observed more frequently in obese patients as compared to patients that are not obese. Due to the increased complications that accompany obesity, obese patients are now more often requiring surgical interventions. Therefore, it is important that anesthesiologists be aware of this development and is equipped to manage these patients effectively and appropriately. As a result, this review highlights the effective management of obese patients undergoing surgery focusing on the preoperative, perioperative and postoperative care of these patients.
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Affiliation(s)
- Rimanatou Seyni-Boureima
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Zongze Zhang
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China.
| | - Malyn M L K Antoine
- Department of Endocrinology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Chrystal D Antoine-Frank
- Department of Anatomical Sciences, St. George's University, True Blue,Grand Anse, West Indies, St. George, Grenada
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Wu YM, Su YH, Huang SY, Lo PH, Chen JT, Chang HC, Yang YL, Cherng YG, Wu HL, Tai YH. Recovery Profiles of Sevoflurane and Desflurane with or without M-Entropy Guidance in Obese Patients: A Randomized Controlled Trial. J Clin Med 2021; 11:jcm11010162. [PMID: 35011903 PMCID: PMC8745589 DOI: 10.3390/jcm11010162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/31/2022] Open
Abstract
Obesity increases the risk of prolonged emergence from general anesthesia due to the delayed release of anesthetic agents from body fat. This trial aimed to evaluate the effects of sevoflurane and desflurane along with anesthetic depth monitoring on emergence time from anesthesia in obese patients. Adults with a body mass index ≥ 30 kg·m−2 undergoing laparoscopic sleeve gastrectomy at a medical center were randomized into four groups: sevoflurane or desflurane anesthesia with or without M-Entropy guidance on anesthetic depth in a ratio of 1:1:1:1. In the M-Entropy guidance groups, the dosage of sevoflurane and desflurane was adjusted to achieve response and state entropy values between 40 and 60 during surgery. In the non-M-Entropy guidance groups, the dosage of anesthetics was titrated according to clinical signs. Primary outcome was time to spontaneous eye opening. A total of 80 participants were randomized. Compared to sevoflurane, desflurane anesthesia significantly reduced the time to spontaneous eye opening [mean difference (MD): −129 s; 95% confidence interval (CI): −211, −46], obeying commands (−160; −243, −77), tracheal extubation (−172; −266, −78), and leaving operating room (−148; −243, −54). M-Entropy guidance further reduced time to eye opening (MD: −142 s; 99.2% CI: −276, −8), tracheal extubation (−199; −379, −19), and leaving operating room (−190; −358, −23) in the desflurane but not the sevoflurane group. M-Entropy guidance significantly reduced the risk of agitation during emergence, i.e., risk difference: −0.275 (95% CI: −0.464, −0.086); and number needed to treat: 4. Compared to sevoflurane, using desflurane to maintain general anesthesia accelerated the return of consciousness in obese patients. M-Entropy guidance further hastened awakening in patients using desflurane and prevented emergence agitation.
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Affiliation(s)
- Yu-Ming Wu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yen-Hao Su
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan;
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Shih-Yu Huang
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Po-Han Lo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hung-Chi Chang
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yun-Ling Yang
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsiang-Ling Wu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (S.-Y.H.); (P.-H.L.); (J.-T.C.); (H.-C.C.); (Y.-L.Y.); (Y.-G.C.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence: ; Tel.: +886-2-27361661 (ext. 3229); Fax: +886-2-27390500
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Ip VHY, Sondekoppam RV, Özelsel TJP. Code red will become Code Blue for humanity: an urgent call for action in the anesthesia community. Can J Anaesth 2021; 69:182-183. [PMID: 34553306 PMCID: PMC8457775 DOI: 10.1007/s12630-021-02116-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vivian H Y Ip
- Department of Anesthesia and Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada.
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Timur J P Özelsel
- Department of Anesthesia and Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada
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Bansal T, Garg K, Katyal S, Sood D, Grewal A, Kumar A. A comparative study of desflurane versus sevoflurane in obese patients: Effect on recovery profile. J Anaesthesiol Clin Pharmacol 2021; 36:541-545. [PMID: 33840938 PMCID: PMC8022057 DOI: 10.4103/joacp.joacp_307_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Anesthesia in obese patients is difficult due to associated comorbidities and altered physiology. Desflurane and sevoflurane have a low fat-blood solubility coefficient and are better suited in these patients to achieve a rapid emergence. We studied BIS guided drug titration to compare the postoperative recovery characteristics and cognitive function of desflurane versus sevoflurane in obese patients undergoing laparoscopic abdominal surgeries. Material and Methods: After institutional ethics committee approval and written informed consent, sixty obese patients (BMI ≥30 kg/m2) were randomized to receive either BIS guided desflurane or sevoflurane. Recovery was assessed by time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person after discontinuation of volatile anesthetic agent. For cognitive function, time taken to complete Mini mental state examination (MMSE) score to baseline was compared in both study groups. Results: Difference of time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person was not significant between both anesthetic groups. Patients in sevoflurane group took significantly (P-value = 0.001) less time (40.07 ± 13 min) to achieve preoperative MMSE score than desflurane group (51.2 ± 11.7 min). Conclusion: Both desflurane and sevoflurane have similar recovery profile in obese patients when anesthetic concentration is carefully titrated. Reversal of cognitive function is significantly earlier in obese patients anesthetized with sevoflurane.
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Affiliation(s)
- Tania Bansal
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Kamakshi Garg
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sunil Katyal
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dinesh Sood
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Anju Grewal
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Arvind Kumar
- Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Weber J, Schmidt J, Wirth S, Schumann S, Philip JH, Eberhart LHJ. Context-sensitive decrement times for inhaled anesthetics in obese patients explored with Gas Man®. J Clin Monit Comput 2021; 35:343-354. [PMID: 32067148 PMCID: PMC7943506 DOI: 10.1007/s10877-020-00477-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/29/2020] [Indexed: 01/24/2023]
Abstract
Anesthesia care providers and anesthesia decision support tools use mathematical pharmacokinetic models to control delivery and especially removal of anesthetics from the patient's body. However, these models are not able to reflect alterations in pharmacokinetics of volatile anesthetics caused by obesity. The primary aim of this study was to refine those models for obese patients. To investigate the effects of obesity on the elimination of desflurane, isoflurane and sevoflurane for various anesthesia durations, the Gas Man® computer simulation software was used. Four different models simulating patients with weights of 70 kg, 100 kg, 125 kg and 150 kg were constructed by increasing fat weight to the standard 70 kg model. For each modelled patient condition, the vaporizer was set to reach quickly and then maintain an alveolar concentration of 1.0 minimum alveolar concentration (MAC). Subsequently, the circuit was switched to an open (non-rebreathing) circuit model, the inspiratory anesthetic concentration was set to 0 and the time to the anesthetic decrements by 67% (awakening times), 90% (recovery times) and 95% (resolution times) in the vessel-rich tissue compartment including highly perfused tissue of the central nervous system were determined. Awakening times did not differ greatly between the simulation models. After volatile anesthesia with sevoflurane and isoflurane, awakening times were lower in the more obese simulation models. With increasing obesity, recovery and resolution times were higher. The additional adipose tissue in obese simulation models did not prolong awakening times and thus may act more like a sink for volatile anesthetics. The results of these simulations should be validated by comparing the elimination of volatile anesthetics in obese patients with data from our simulation models.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James H Philip
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Leopold H J Eberhart
- Department of Anaesthesiology and Intensive Care, Philipps-Universität Marburg, Marburg, Germany
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10
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Arain SR, Yu S, Dugan S, Pagel PS, Ebert TJ. Titration of sevoflurane anesthesia to optimize the time to regain airway reflexes in patients undergoing elective surgery: A randomized clinical trial comparing desflurane and sevoflurane anesthesia. Acta Anaesthesiol Scand 2020; 64:729-734. [PMID: 32057088 DOI: 10.1111/aas.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Desflurane has adverse environmental effects, but has clinical advantages to speed emergence and return of protective airway reflexes compared with sevoflurane. We hypothesized that weaning of the inspired sevoflurane during the final 15 minutes of surgery would eliminate differences in airway reflex recovery between these agents. METHODS After obtaining IRB approval and informed consent, 40 patients undergoing elective surgery (≥1-hour) randomly received desflurane or sevoflurane. Patients swallowed 20 mL of water without drooling or coughing, and then received sedation and PONV pre-medication. Anesthesia was induced using propofol and fentanyl and maintained with desflurane or sevoflurane through a laryngeal mask airway maintaining a bispectral index of 45-50 and 50-60 during the final 15 minutes before surgery end. Cardiorespiratory variables and age-adjusted minimal alveolar concentration were recorded. The duration between anesthetic discontinuation and first appropriate response to command was measured; the laryngeal mask airway was removed. Two minutes after responding to command, patients were positioned semi-upright and attempted to swallow water. If successful swallowing was not achieved, the test was repeated every 4 minutes after each failure until successful swallowing was achieved. RESULTS Average anesthetic concentration and bispectral index was similar in patients receiving desflurane vs sevoflurane. Response times after discontinuation of anesthetics were similar. There were no differences in the recovery of swallowing ability between desflurane and sevoflurane groups. CONCLUSION Weaning of sevoflurane during the final 15 minutes of surgery eliminates clinical advantages of the more rapid return of airway reflexes with desflurane.
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Affiliation(s)
- Shahbaz R. Arain
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Sherman Yu
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Shannon Dugan
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Paul S. Pagel
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Thomas J. Ebert
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
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Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, Doufas AG, Yilmaz M, Stein MH, Krajewski ML, Singh M, Pichler L, Ramachandran SK, Chung F. Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2019; 127:967-987. [PMID: 29944522 PMCID: PMC6135479 DOI: 10.1213/ane.0000000000003434] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Crispiana Cozowicz
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
| | - David T Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anthony G Doufas
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California
| | - Meltem Yilmaz
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - Mark H Stein
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Megan L Krajewski
- Department of Anesthesia, Critical Care, and Pain Management, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mandeep Singh
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Satya Krishna Ramachandran
- Department of Anesthesiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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12
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de Sousa GC, Cruz FF, Heil LB, Sobrinho CJS, Saddy F, Knibel FP, Pereira JB, Schultz MJ, Pelosi P, Gama de Abreu M, Silva PL, Rocco PRM. Intraoperative immunomodulatory effects of sevoflurane versus total intravenous anesthesia with propofol in bariatric surgery (the OBESITA trial): study protocol for a randomized controlled pilot trial. Trials 2019; 20:300. [PMID: 31138279 PMCID: PMC6540380 DOI: 10.1186/s13063-019-3399-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Obesity is associated with a chronic systemic inflammatory process. Volatile or intravenous anesthetic agents may modulate immune function, and may do so differentially in obesity. However, no study has evaluated whether these potential immunomodulatory effects differ according to type of anesthesia in obese patients undergoing laparoscopic bariatric surgery. Methods/design The OBESITA trial is a prospective, nonblinded, single-center, randomized, controlled clinical pilot trial. The trial will include 48 patients with a body mass index ≥ 35 kg/m2, scheduled for laparoscopic bariatric surgery using sleeve or a Roux-en-Y gastric bypass technique, who will be allocated 1:1 to undergo general inhalational anesthesia with sevoflurane or total intravenous anesthesia (TIVA) with propofol. The primary endpoint is the difference in plasma interleukin (IL)-6 levels when comparing the two anesthetic agents. Blood samples will be collected prior to anesthesia induction (baseline), immediately after anesthetic induction, and before endotracheal extubation. Levels of other proinflammatory and anti-inflammatory cytokines, neutrophil chemotaxis, macrophage differentiation, phagocytosis, and occurrence of intraoperative and postoperative complications will also be evaluated. Discussion To our knowledge, this is the first randomized clinical trial designed to compare the effects of two different anesthetics on immunomodulation in obese patients undergoing laparoscopic bariatric surgery. Our hypothesis is that anesthesia with sevoflurane will result in a weaker proinflammatory response compared to anesthesia with propofol, with lower circulating levels of IL-6 and other proinflammatory mediators, and increased macrophage differentiation into the M2 phenotype in adipose tissue. Trial registration Registro Brasileiro de Ensaios Clínicos, RBR-77kfj5. Registered on 25 July 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3399-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giselle Carvalho de Sousa
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.,Department of Anesthesiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda Ferreira Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Luciana Boavista Heil
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | | | - Felipe Saddy
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.,Institute D'Or of Research and Teaching, Rio de Janeiro, Brazil
| | | | | | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.
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13
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Hebbes C, Thompson J. Pharmacokinetics of anaesthetic drugs at extremes of body weight. BJA Educ 2018; 18:364-370. [PMID: 33456803 PMCID: PMC7808064 DOI: 10.1016/j.bjae.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- C.P. Hebbes
- University Hospitals of Leicester NHS Trust, Leicester, UK
- University of Leicester, Leicester, UK
| | - J.P. Thompson
- University Hospitals of Leicester NHS Trust, Leicester, UK
- University of Leicester, Leicester, UK
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14
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Comparison of the Recovery Profile between Desflurane and Sevoflurane in Patients Undergoing Bariatric Surgery-a Meta-Analysis of Randomized Controlled Trials. Obes Surg 2018; 27:3031-3039. [PMID: 28916989 DOI: 10.1007/s11695-017-2929-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Early and clear recovery from anesthesia is the crux for preventing perioperative complications in the obese undergoing bariatric surgery. Volatile inhalation agents by virtue of high lipid solubility are expected to produce residual anesthetic effects. Prospective randomized trials comparing desflurane and sevoflurane used for anesthesia maintenance (electroencephalograph guided) during bariatric surgery published till 1st of July 2017 were searched in the medical database. Comparisons were made for surrogate markers of recovery from anesthesia that included time to eye-opening (TEo), time to tracheal-extubation (TEx), and Aldrete scores on immediately shifting to recovery (Ald-I). Five trials were included in the final analysis. Patients receiving desflurane began to respond faster by opening eyes on command (five trials) by 3.80 min (95%CI being 1.83-5.76) (random effects, P < 0.01, I2 = 78.61%), and tracheal extubation was also performed earlier (four trials) by 4.97 min (95%CI being 1.34-8.59). This meant a reduction of 37% in TEo and 33.60% in TEx over sevoflurane. Ald-I scores were higher/better with desflurane by 0.52 (95%CI being 0.19-0.84) (Fixed-effects, P < 0.01, I2 = 6.67%). Publication bias is likely for TEo (Egger's Test, X-intercept = - 8.57, P = 0.02). No airway-related complications were reported with desflurane's expedited recovery. Use of desflurane compared to sevoflurane for maintenance of anesthesia in morbidly obese patients allows attaining verbal contact faster, and tracheal extubating can be performed earlier without compromising safety. The benefits of better recovery extend into the immediate postoperative phase with patients being more awake upon shifting to the recovery.
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15
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Chidambaran V, Tewari A, Mahmoud M. Anesthetic and pharmacologic considerations in perioperative care of obese children. J Clin Anesth 2018; 45:39-50. [DOI: 10.1016/j.jclinane.2017.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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16
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Neisi A, Albooghobeish M, Geravandi S, Adeli Behrooz HR, Mahboubi M, Omidi Khaniabad Y, Valipour A, Karimyan A, Mohammadi MJ, Farhadi M, Yari AR, Ghomeishi A. Investigation of health risk assessment sevoflurane on indoor air quality in the operation room in Ahvaz city, Iran. TOXIN REV 2018. [DOI: 10.1080/15569543.2018.1434796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Abdolkazem Neisi
- Department of Environmental Health Engineering, School of Public Health and Environmental Technologies Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Masoumeh Albooghobeish
- Department of Anesthesiology, Paramedical School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | | | | | - Yusef Omidi Khaniabad
- Health Care System of Karoon, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | | | - Mohammad Javad Mohammadi
- Department of Environmental Health Engineering, School of Public Health and Environmental Technologies Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Majid Farhadi
- Nutrition Health Research Center, Department of Environmental Health, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ahmad Reza Yari
- Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran
| | - Ali Ghomeishi
- Department of Anesthesiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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17
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Lang LH, Parekh K, Tsui BYK, Maze M. Perioperative management of the obese surgical patient. Br Med Bull 2017; 124:135-155. [PMID: 29140418 PMCID: PMC5862330 DOI: 10.1093/bmb/ldx041] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/29/2017] [Accepted: 10/10/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The escalation in the prevalence of obesity throughout the world has led to an upsurge in the number of obese surgical patients to whom perioperative care needs to be delivered. SOURCES OF DATA After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered. AREAS OF AGREEMENT There were no controversies regarding preoperative management and the intraoperative care of the obese surgical patient. AREAS OF CONTROVERSY Is there a healthy obese state that gives rise to the obesity paradox regarding postoperative complications? GROWING POINTS This review considers how to prepare for and manage the obese surgical patient through the entire spectrum, from preoperative assessment to possible postoperative intensive care. AREAS TIMELY FOR DEVELOPING RESEARCH What results in an obese patient developing 'unhealthy' obesity?
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Affiliation(s)
- L H Lang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue Box 1363, San Francisco, CA 94143, USA
| | - K Parekh
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue Box 1363, San Francisco, CA 94143, USA
| | - B Y K Tsui
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue Box 1363, San Francisco, CA 94143, USA
| | - M Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue Box 1363, San Francisco, CA 94143, USA
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18
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Heil LBB, Silva PL, Pelosi P, Rocco PRM. Immunomodulatory effects of anesthetics in obese patients. World J Crit Care Med 2017; 6:140-152. [PMID: 28828299 PMCID: PMC5547428 DOI: 10.5492/wjccm.v6.i3.140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/27/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
Anesthesia and surgery have an impact on inflammatory responses, which influences perioperative homeostasis. Inhalational and intravenous anesthesia can alter immune-system homeostasis through multiple processes that include activation of immune cells (such as monocytes, neutrophils, and specific tissue macrophages) with release of pro- or anti-inflammatory interleukins, upregulation of cell adhesion molecules, and overproduction of oxidative radicals. The response depends on the timing of anesthesia, anesthetic agents used, and mechanisms involved in the development of inflammation or immunosuppression. Obese patients are at increased risk for chronic diseases and may have the metabolic syndrome, which features insulin resistance and chronic low-grade inflammation. Evidence has shown that obesity has adverse impacts on surgical outcome, and that immune cells play an important role in this process. Understanding the effects of anesthetics on immune-system cells in obese patients is important to support proper selection of anesthetic agents, which may affect postoperative outcomes. This review article aims to integrate current knowledge regarding the effects of commonly used anesthetic agents on the lungs and immune response with the underlying immunology of obesity. Additionally, it identifies knowledge gaps for future research to guide optimal selection of anesthetic agents for obese patients from an immunomodulatory standpoint.
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19
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A clinical review of inhalation anesthesia with sevoflurane: from early research to emerging topics. J Anesth 2017; 31:764-778. [PMID: 28585095 PMCID: PMC5640726 DOI: 10.1007/s00540-017-2375-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
A large number of studies during the past two decades have demonstrated the efficacy and safety of sevoflurane across patient populations. Clinical researchers have also investigated the effects of sevoflurane, its hemodynamic characteristics, its potential protective effects on several organ systems, and the incidence of delirium and cognitive deficiency. This review examines the clinical profiles of sevoflurane and other anesthetic agents, and focuses upon emerging topics such as organ protection, postoperative cognitive deficiency and delirium, and novel ways to improve postanesthesia outcomes.
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20
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Abstract
Obesity has increased in incidence worldwide. Along with the increased number of obese patients, comorbid conditions are also more prevalent in this population. Obesity leads to changes in the physiology of patients along with an altered response to pharmacologic therapy. Vigilant perioperative physicians must be aware of the unique characteristics of administered agents in order to appropriately provide anesthetic care for obese patients. Because of the variability in tissue content in obese patients and changes in pharmacokinetic modeling, a one-size-fits-all approach is not justified and a more sophisticated and prudent approach is indicated.
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Affiliation(s)
- Simon Willis
- Department of Physical Medicine and Rehabilitation, MedStar Georgetown University Hospital/National Rehabilitation Hospital, 102 Irving Street Northwest, Washington, DC 20010, USA
| | - Gregory J Bordelon
- Department of Anesthesiology, Louisiana State University Medical Center, 1542 Tulane Avenue, Room 659, New Orleans, LA 70112, USA
| | - Maunak V Rana
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA.
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21
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Mecoli M, Kandil A, Campion M, Samuels P. Pediatric Obesity: Anesthetic Implications and Perioperative Considerations for Weight Loss Surgery. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0211-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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22
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Jain RA, Shetty AN, Oak SP, Wajekar AS, Garasia MB. Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study. Indian J Anaesth 2017; 61:42-47. [PMID: 28216703 PMCID: PMC5296807 DOI: 10.4103/0019-5049.198408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used. Methods: Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A) or atracurium infusion to keep train-of-four count 2 (Group B). The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann–Whitney test. Results: The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02). The brain relaxation scores were comparable among the two groups (P = 0.27). Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups. Conclusion: The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.
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Affiliation(s)
- Ruchi A Jain
- Department of Anaesthesia, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Anita N Shetty
- Department of Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shrikanta P Oak
- Department of Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anjana S Wajekar
- Department of Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Madhu B Garasia
- Department of Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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23
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The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy. J Clin Anesth 2016; 35:441-445. [DOI: 10.1016/j.jclinane.2016.08.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 08/14/2016] [Indexed: 11/16/2022]
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24
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Anesthetic considerations for pediatric obesity and adolescent bariatric surgery. Curr Opin Anaesthesiol 2016; 29:327-36. [DOI: 10.1097/aco.0000000000000330] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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25
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Postoperative recovery after anesthesia in morbidly obese patients: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2015; 62:907-17. [PMID: 26001751 DOI: 10.1007/s12630-015-0405-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 05/15/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Obese patients present a challenge to safe general anesthesia because of impaired cardiopulmonary physiology and increased risks of aspiration and acute upper airway obstruction. Since studies are lacking regarding the postoperative effects on recovery from general anesthesia in morbidly obese patients, we conducted a systematic review and meta-analysis of recovery outcomes in morbidly obese patients who had undergone general anesthesia. SOURCE We systematically searched the PubMed, EMBASE™, Cochrane, and Scopus™ databases for randomized controlled trials that evaluated the outcome of anesthesia with desflurane, sevoflurane, isoflurane, or propofol in morbidly obese patients. Using a random effects model, we conducted meta-analyses to assess recovery times (eye opening, hand squeezing, tracheal extubation, and stating name or birth date), time to discharge from the postanesthesia care unit (PACU), and the incidence and severity of postoperative nausea and vomiting (PONV). PRINCIPAL FINDINGS We reviewed results for 11 trials and found that patients given desflurane took less time: to respond to commands to open their eyes (weighted mean difference [WMD] -3.10 min; 95% confidence interval (CI): -5.13 to -1.08), to squeeze the investigator's hand (WMD -7.83 min; 95% CI: -8.81 to -6.84), to be prepared for tracheal extubation (WMD -3.88 min; 95% CI: -7.42 to -0.34), and to state their name (WMD -7.15 min; 95% CI: -11.00 to -3.30). We did not find significant differences in PACU discharge times, PONV, or the PACU analgesic requirement. CONCLUSION Postoperative recovery was significantly faster after desflurane than after sevoflurane, isoflurane, or propofol anesthesia in obese patients. No clinically relevant differences were observed regarding PACU discharge time, incidence of PONV, or postoperative pain scores. The systematic review was registered with PROSPERO (CRD42014009480).
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Abstract
The prevalence of obesity is increasing worldwide. For severely obese patients, bariatric surgery is the only effective option for sustained weight loss and associated health improvement. As a consequence, the number of bariatric surgical procedures being performed is growing exponentially. Systematic knowledge regarding the effect of obesity on the pharmacokinetics and pharmacodynamics of anesthetic agents is generally lacking, and data for morbidly obese (body mass index [BMI] 40-49 kg/m2)) and super-obese patients (BMI > 50 kg/m2) are almost completely non-existent. Most drug-dosing guidelines are based on results from relatively small studies in moderately obese patients. Future systematic pharmacological research is needed for improved and more rational peri-operative care of morbidly obese patients.
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Affiliation(s)
- Hendrikus J M Lemmens
- Stanford University School of Medicine, Department of Anesthesia Stanford, CA 94305, USA.
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27
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Raveendran R, Chung F. Perioperative Management of the Morbidly Obese. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e318295d49b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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de Oliveira GS, Girao W, Fitzgerald PC, McCarthy RJ. The effect of sevoflurane versus desflurane on the incidence of upper respiratory morbidity in patients undergoing general anesthesia with a Laryngeal Mask Airway: a meta-analysis of randomized controlled trials. J Clin Anesth 2013; 25:452-8. [DOI: 10.1016/j.jclinane.2013.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 02/20/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
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29
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Abstract
Anesthesiologists are increasingly being faced with treating obese patients. Physiologic and anthropometric associated with obesity-most notably increases in cardiac output, changes in tissue perfusion and increases in total body weight (TBW), lean body weight (LBW), and fat mass affect the pharmacokinetics (PK) of anesthetic agents. In addition, redundancy of airway tissue, obstructive and central sleep apnea and CO2 retention affect the pharmacodynamics (PD) of anesthetics and narrow the therapeutic window of numerous anesthetic drugs. Safe and effective pharmacologic management of the obese patient requires a thorough understanding of how obesity affects the PK and PD of anesthetics.
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Affiliation(s)
- Jerry Ingrande
- Instructor, Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive Room H3580, Stanford, California 94305, (phone) 650-723-7377, (fax) 650-725-8544,
| | - Hendrikus JM Lemmens
- Professor, Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive Room H3580, Stanford, California 94305, (phone) 650-723-7377, (fax) 650-725-8544,
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Les pièges pour l’anesthésiste en chirurgie bariatrique que le chirurgien doit connaître. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s11690-012-0338-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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JAKOBSSON J. Desflurane: a clinical update of a third-generation inhaled anaesthetic. Acta Anaesthesiol Scand 2012; 56:420-32. [PMID: 22188283 DOI: 10.1111/j.1399-6576.2011.02600.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2011] [Indexed: 12/30/2022]
Abstract
Available volatile anaesthetics are safe and efficacious; however, their varying pharmacology provides small but potentially clinically important differences. Desflurane is one of the third-generation inhaled anaesthetics. It is the halogenated inhaled anaesthetic with the lowest blood and tissue solubilities, which promotes its rapid equilibration and its rapid elimination following cessation of administration at the end of anaesthesia. The low fat solubility of desflurane provides pharmacological benefits, especially in overweight patients and in longer procedures by reducing slow compartment accumulation. A decade of clinical use has provided evidence for desflurane's safe and efficacious use as a general anaesthetic. Its benefits include rapid and predictable emergence, and early recovery. In addition, the use of desflurane promotes early and predictable extubation, and the ability to rapidly transfer patients from the operating theatre to the recovery area, which has a positive impact on patient turnover. Desflurane also increases the likelihood of patients, including obese patients, recovering their protective airway reflexes and awakening to a degree sufficient to minimise the stay in the high dependency recovery area. The potential impact of the rapid early recovery from desflurane anaesthesia on intermediate and late recovery and resumption of activities of daily living requires further study.
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Affiliation(s)
- J. JAKOBSSON
- Department of Anaesthesia and Intensive Care; Institution for Physiology and Pharmacology; Karolinska Institute; Danderyds University Hospital; Stockholm; Sweden
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Abstract
Obesity is increasing in the population as a whole, and especially in the obstetric population, among whom pregnancy-induced physiological changes impact on those already present due to obesity. In particular, changes in the cardiovascular and respiratory systems during pregnancy further alter the physiological effects and comorbidities of obesity. Obese pregnant women are at increased risk of diabetes, hypertensive disorders of pregnancy, ischaemic heart disease, congenital malformations, operative delivery, postpartum infection and thromboembolism. Regional analgesia and anaesthesia is usually preferred but may be challenging. Obese pregnant women appear to have increased morbidity and mortality associated with caesarean delivery and general anaesthesia for caesarean delivery in particular, and more anaesthesia-related complications. This article summarises the physiological and pharmacological implications of obesity and pregnancy and describes the issues surrounding the management of these women for labour and delivery.
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Affiliation(s)
- H. S. Mace
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - M. J. Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
- Pharmacology and Anaesthesiology Unit, The School of Medicine and Pharmacology, The University of Western Australia
| | - N. J. Mcdonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
- School of Women's and Infants’ Health and School of Medicine and Pharmacology, The University of Western Australia
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Abstract
The prevalence of childhood obesity is increasing. The focus of this review is the special anesthetic considerations regarding the perioperative management of obese children. With obesity the risk of comorbidity such as asthma, obstructive sleep apnea, hypertension, and diabetes increases. The obese child has an increased risk of perioperative complications especially related to airway management and ventilation. There is a significantly increased risk of difficult mask ventilation and perioperative desaturation. Furthermore, obesity has an impact on the pharmacokinetics of most anesthetic drugs. This has important implications on how to estimate the optimal drug dose. This article offers a review of the literature on definition, prevalence and the pathophysiology of childhood obesity and provides suggestions on preanesthetic evaluation, airway management and dosage of the anesthetic drugs in these patients. The authors highlight the need of supplemental studies on various areas of the subject.
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Affiliation(s)
- Anette Mortensen
- Department of Anesthesiology, Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient. Eur J Anaesthesiol 2011; 28:120-4. [PMID: 21088598 DOI: 10.1097/eja.0b013e3283405048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE This prospective, randomised double-blind study compared the effects of target control infusion (TCI) of sufentanil and remifentanil on the quality of recovery and post-operative pain control in morbidly obese patients undergoing laparoscopic gastroplasty. METHODS Following institutional Ethics Committee approval and written informed consent, 100 morbidly obese patients were randomised to receive either TCI sufentanil (0.3 ng ml⁻¹; S-group; N = 50) or TCI remifentanil (3 ng ml⁻¹; R-group; N = 50) in combination with desflurane (O₂/air mixture: FiO₂, 50%). Quality of recovery was estimated by means of the modified Aldrete score and by the ability to perform psychomotor tests with the same competence post-operatively as pre-operatively. Post-operative pain was evaluated by the quantity of piritramide needed to achieve a visual analogue scale (VAS) less than 3. Statistical analysis was performed using an unpaired Student's t-test, Mann-Whitney U-test and χ² test, as appropriate. RESULTS Patient and surgical characteristics were similar among groups. In the R-group, time to extubation was significantly shorter, but VAS significantly higher than that in the S-group (P < 0.01). Quality of recovery and duration of post-anaesthesia care unit stay were comparable between groups (S-group: 119 ± 27 min and R-group: 119 ± 35 min). Piritramide consumption during the first 4 post-operative hours was higher in the R-group than in the S-group [S-group (median, range): 11.5 mg, 5.5-16.0; R-group: 18.0 mg, 14-22, P < 0.01], but not later on. CONCLUSION In the conditions of the present study, although TCI sufentanil resulted in slower awakening than TCI remifentanil, it was associated with a better quality of recovery.
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Abstract
The incidence of childhood obesity ranges today from approximately 8% to 17%, and is an increasing issue in developed and developing countries. This disease will become increasingly significant in paediatric anaesthesia. Obese children not only have anaesthesia-relevant co-existing diseases, that are, asthma and hypertension, but also have a higher incidence of anaesthesia-related complication. This review covers current definition and some epidemiology of childhood obesity. It summarises potential co-morbidities and provides details for preoperative evaluation, anaesthetic management and prevention of perioperative complications.
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Affiliation(s)
- Claudia Philippi-Höhne
- University of Leipzig, Department of Anesthesiology and Intensive Care Medicine, Liebigstrasse 20, 04103 Leipzig, Germany.
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Abstract
Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. Intra-operative hypoxaemia can be treated with the combination of PEEP and recruitment manoeuvres, and attention to airway management at emergence is critical. Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.
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Affiliation(s)
- Roman Schumann
- Tufts Medical Center, Department of Anaesthesiology, Tufts University School of Medicine, 800 Washington St., Boston, MA 02111, USA.
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Ingrande J, Lemmens H. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth 2010; 105 Suppl 1:i16-23. [DOI: 10.1093/bja/aeq312] [Citation(s) in RCA: 296] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Effects of A-Line Autoregression Index (AAI) Monitoring on Recovery After Sevoflurane Anesthesia for Bariatric Surgery. Obes Surg 2010; 21:850-7. [DOI: 10.1007/s11695-010-0150-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Dexter F, Bayman EO, Epstein RH. Statistical Modeling of Average and Variability of Time to Extubation for Meta-Analysis Comparing Desflurane to Sevoflurane. Anesth Analg 2010; 110:570-80. [DOI: 10.1213/ane.0b013e3181b5dcb7] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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O'Neill T, Allam J. Anaesthetic considerations and management of the obese patient presenting for bariatric surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.cacc.2009.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Candiotti K, Sharma S, Shankar R. Obesity, obstructive sleep apnoea, and diabetes mellitus: anaesthetic implications. Br J Anaesth 2009; 103 Suppl 1:i23-30. [DOI: 10.1093/bja/aep294] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Schumann R, Jones SB, Cooper B, Kelley SD, Bosch MV, Ortiz VE, Connor KA, Kaufman MD, Harvey AM, Carr DB. Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004-2007. Obesity (Silver Spring) 2009; 17:889-94. [PMID: 19396068 DOI: 10.1038/oby.2008.569] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To reevaluate and update evidence-based best practice recommendations published in 2004 for anesthetic perioperative care and pain management in weight loss surgery (WLS), we performed a systematic search of English-language literature on anesthetic perioperative care and pain management in WLS published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. We identified relevant abstracts by using key words, retrieved full text articles, and stratified the resulting evidence according to systems used in established evidence-based models. We updated prior evidence-based best practice recommendations based upon interim literature. In instances of controversial or inadequate scientific evidence, the task force reached consensus recommendations following evaluation of the best available information and expert opinion. The search yielded 1,788 abstracts, with 162 potentially relevant titles; 45 were reviewed in detail. Despite more information on perioperative management of patients with obstructive sleep apnea (OSA), evidence to support preoperative testing and treatment or to guide perioperative monitoring is scarce. New evidence on appropriate intraoperative dosing of muscle relaxants allows for greater precision in their use during WLS. A novel application of alpha-2 agonists for perioperative anesthetic care is emerging. Key elements that may enhance patient safety include integration of the latest evidence on WLS, obesity, and collaborative multidisciplinary care into clinical care. However, large gaps remain in the evidence base.
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Affiliation(s)
- Roman Schumann
- Department of Anesthesia, Tufts-New England Medical Center, Boston, Massachusetts, USA.
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45
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Lemmens HJM, Saidman LJ, Eger EI, Laster MJ. Obesity Modestly Affects Inhaled Anesthetic Kinetics in Humans. Anesth Analg 2008; 107:1864-70. [DOI: 10.1213/ane.0b013e3181888127] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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La Colla L, Albertin A, La Colla G, Mangano A. Faster wash-out and recovery for desflurane vs sevoflurane in morbidly obese patients when no premedication is used. Br J Anaesth 2007; 99:353-8. [PMID: 17621601 DOI: 10.1093/bja/aem197] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The aim of this study was to compare desflurane vs sevoflurane kinetics and dynamics in morbidly obese patients and their recovery profile when no premedication had been used. METHODS Twenty-eight unpremedicated obese patients were randomly allocated to receive either sevoflurane (n = 14) or desflurane (n = 14) as the main anaesthetic agent. After induction of anaesthesia, either sevoflurane 2% or desflurane 6% was administered for 30 min via a non-rebreathing circuit. The kinetics of sevoflurane and desflurane were determined by measuring and recording end-tidal samples during this time. The bispectral index was used to indicate the level of hypnosis. At the end of the procedure, the end-tidal concentrations of sevoflurane and desflurane were recorded during the first 5 min after stopping their administration. Time from discontinuation of the anaesthetic drugs to eye opening on verbal command, squeezing the observer's hand on command, extubation, stating their name, giving their correct date of birth, discharge from the recovery room, and duration of the surgery and anaesthesia were also recorded. RESULTS The F(A)/F(I) ratio was significantly higher in the desflurane group from the 15th to the 30th min. The wash-out phase was faster for desflurane during the total observation period. When desflurane was used, recovery was also faster. CONCLUSIONS Desflurane provides faster wash-in and wash-out than sevoflurane in morbidly obese patients, and recovery is much faster after desflurane administration when no premedication has been used.
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Affiliation(s)
- L La Colla
- Department of Anesthesiology, Vita-Salute San Raffaele University School of Medicine, IRCCS San Raffaele, Milan, Italy.
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De Baerdemaeker LEC, Jacobs S, Pattyn P, Mortier EP, Struys MMRF. Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity. Br J Anaesth 2007; 99:404-11. [PMID: 17606479 DOI: 10.1093/bja/aem164] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Choice of opioid may influence postoperative pain, recovery, and respiratory homeostasis in morbid obesity. The aim of this study was to compare the effects of target-controlled infusions (TCIs) of remifentanil or sufentanil on postoperative analgesia, recovery, and pulmonary function after laparoscopic gastric banding. METHODS Forty morbidly obese patients undergoing laparoscopic gastric banding received BIS-guided desflurane anaesthesia combined with remifentanil TCI (Group R) or sufentanil TCI (Group S). Intraoperative haemodynamic stability, BIS controllability, and immediate recovery in the operating room were measured. Pulmonary function, modified Aldrete score, modified Observers Assessment of Alertness and Sedation score, blood gas analysis, and visual analogue score for pain and postoperative nausea and vomiting were measured on admission to the post-anaesthesia care unit and 30, 60, 120 min afterwards. After operation, patients received patient-controlled analgesia with morphine. RESULTS During the first two postoperative hours, cumulative morphine consumption was higher in the remifentanil group compared with the sufentanil group, but was equal values after that time. Recovery profiles and spirometry showed no significant differences. During maintenance, remifentanil gave a better haemodynamic stability. CONCLUSIONS As few differences occurred in the postoperative period, the theoretical advantage of remifentanil over the longer acting sufentanil can be questioned when using TCI technology.
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Vallejo MC, Sah N, Phelps AL, O'Donnell J, Romeo RC. Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients. J Clin Anesth 2007; 19:3-8. [PMID: 17321919 DOI: 10.1016/j.jclinane.2006.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 03/04/2006] [Accepted: 04/11/2006] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To determine if desflurane results in a faster emergence as measured by time to eye opening compared to sevoflurane in morbidly obese patients undergoing laparoscopic gastroplasty. STUDY DESIGN Prospective, randomized, double-blinded study. SETTING Tertiary care hospital. PATIENTS 70 patients with a body mass index of 35 or higher undergoing laparoscopic gastroplasty. INTERVENTIONS Patients were randomized into two groups to receive either desflurane or sevoflurane for maintenance of general anesthesia. MEASUREMENTS Intraoperative measured variables included the time from when the inhalation agent was turned off (no agent delivered) to eye opening and the time from when the inhalation agent was turned off to extubation. Postanesthesia care unit (PACU)-measured variables on admission and at 15 minute intervals until discharge included oxygen saturation (Spo2), blood pressure, heart rate, pain and nausea Visual Analog Scale (VAS) scores, emesis, modified Aldrete score, and Mini-Mental Status (MMS) examination score. MAIN RESULTS No differences were noted in demographic data, total surgical operative time, times from turning inhalation agent off to eye opening and extubation, or average length of stay in PACU. No differences were noted with respect to pain VAS, treatment for pain, modified Aldrete scores, emesis, or treatment for postoperative nausea or emesis. Differences were noted in PACU nausea VAS at 15 minutes, PACU nausea VAS at discharge, and PACU-MMS score at 45 minutes; however, multivariate analysis of variance revealed no differences between groups over the repeated PACU measured time periods in nausea VAS (P=0.17) or in MMS (P=0.34). Higher heart rates in the desflurane group were observed during PACU admission (82.3+/-9.8 vs 74.4+/-13.4 bpm, P<0.01) and 15 minutes post PACU admission (79.4+/-12.1 vs 71.3+/-13.2 bpm, P=0.01). CONCLUSIONS In morbidly obese patients undergoing laparoscopic gastroplasty, emergence, as measured by time to eye opening, did not differ between desflurane and sevoflurane, with similar recovery characteristics.
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Affiliation(s)
- Manuel C Vallejo
- Department of Anesthesiology, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, PA 15213, USA.
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Abstract
The anesthetic management of the MO patient requires an important focus on a number of issues beginning with a careful preoperative evaluation and synthesizing pre-existing disease processes with the anesthetic management plan. The common misperception that all MO patients are "full stomach" has been challenged and may be a nonissue. New approaches to pre-oxygenation to lessen the likelihood of desaturation during apnea may be a valuable tool if difficulty is encountered in tracheal intubation. In addition, promising results have been demonstrated with the use of the ILMA for ventilation and for blindly establishing tracheal tube placement. Proper patient positioning is essential to aid in successful intubation when a laryngoscope is employed. Intraoperative anesthetic management can be guided with a processed electroencephalogram monitor to help improve emergence and to enhance wakefulness in the PACU. Careful consideration must be given to postoperative analgesic needs by minimizing the use of opioids and employing nonopioid analgesics including NSAIDs, alpha2-adrenergic agonists, and low doses of ketamine.
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Affiliation(s)
- Thomas J Ebert
- The Medical College of Wisconsin, VA Medical Center, Anesthesiology/112A, 5000 W. National Avenue, Milwaukee, WI 53295, USA.
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Lohser J, Kulkarni V, Brodsky JB. Anesthesia for thoracic surgery in morbidly obese patients. Curr Opin Anaesthesiol 2007; 20:10-4. [PMID: 17211160 DOI: 10.1097/aco.0b013e32800ff73c] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review considers the anesthetic management of obese patients undergoing thoracic surgery. Extremely or morbidly obese patients differ from patients of normal weight in several ways. Obese patients have altered anatomy and physiology, and usually have associated comorbid medical conditions that may complicate their operative course and increase their risks for postoperative complications. RECENT FINDINGS During anesthetic induction and laryngoscopy for tracheal intubation the morbidly obese patient should be in the reverse Trendelenburg position with the head and neck elevated above the table. Placement of a double-lumen tube should be no more difficult in an obese patient than in a normal-weight patient. There are no clear advantages for any of the commonly available inhalational anesthetic agents and each can be used for general anesthesia. SUMMARY With proper attention to their special needs, the morbidly obese patient can safely undergo thoracic surgery and one-lung ventilation.
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Affiliation(s)
- Jens Lohser
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
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